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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200017
Report Date: 12/12/2022
Date Signed: 12/19/2022 04:59:31 PM

Document Has Been Signed on 12/19/2022 04:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:TOLEDO RESIDENTIAL HOME CARE IIIFACILITY NUMBER:
275200017
ADMINISTRATOR:KATHERINE TOLEDOFACILITY TYPE:
735
ADDRESS:2142 PEREZ STREETTELEPHONE:
(831) 443-8336
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 5DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Katherine ToledoTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Katherine Toledo Continual Administrator's Certification expired on 11/20/2022 and has been submitted for renewal. There are currently 5 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

LPA Hurt observed the facility dryer being used as storage, and the residents clothing being hung to dry on clothing lines in garage area. LPA Hurt observed the facility bedrooms are not being used as labeled on facility sketch submitted to Licensing.LPA Hurt measured the water temperature in the bathroom near the back sliding glass door at 122 degrees. LPA Hurt observed a large dog aggressively barking, and growling inside a kennel near the kitchen area.

There following deficiencies were observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Katherine Toledo and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/19/2022 04:59 PM - It Cannot Be Edited


Created By: Sarah Hurt On 12/12/2022 at 01:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TOLEDO RESIDENTIAL HOME CARE III
FACILITY NUMBER: 275200017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2022
Section Cited

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80022 Plan of Operation (7) A sketch of the building(s) to be occupied, including a floor plan which describes the capacities of the buildings for the uses intended, room dimensions, and a designation of the rooms to be used for nonambulatory clients, if any. The following requirement has not been met as evidenced by:
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Administrator has changed around the usage of the bedrooms. The facility staff room, and facility office have been switched around, and no longer match facility sketch submitted to Licensing, which poses a potential, health, safety, or personal rights risk to residents in care.
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Type B
12/26/2022
Section Cited

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80088 Furniture, Fixtures, Equipment, and Supplies. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). The following requirement has not been met as evidenced by:

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LPA measured hot water in bathroom at 123 degrees outside of regulation which poses a potential health, safety,or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
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